NOTE: If benefits for a hearing aid are available, the following criteria apply. (See below for state mandate for Oregon members).

Hearing aids that are FDA-approved and dispensed by prescription may be considered medically necessary for a moderate hearing loss of 40 to 60 dB (based on pure tone average bone-conduction detection threshold) for any of the following:

Conductive hearing loss (external and middle ear blockage/damage/disease) that is unresponsive to medical/surgical interventions OR

Traditional hearing aids are externally worn microphones that amplify sound to the ear through an ear mold that fits in the ear canal. (See Definition of Terms below)

Selection of the hearing aid is based on the results from a complete work-up performed by a hearing professional that includes skilled hearing tests and assessment along with fitting the chosen device.

The hearing aid dispensed should meet the hearing requirements of the member in the environments and under the conditions where enhanced hearing is needed.

Required Documentation

Documentation must include ALL of the following information:

Written prescription from the examining physician/licensed healthcare provider within the past 6 months

History of prior use or current use of a hearing aid (not applicable if the member has never had a hearing aid)

Recommendation for the type of hearing aid technology that is appropriate for the member

Follow up plan for assessing the effectiveness/outcome of using a hearing aid - A trial period may be needed to test the usability of a specific hearing aid model/type.

Definition of Terms

Audiometric testing: Diagnostic tests that evaluate the ability to hear sounds. The intensity (loudness) of sound is measured in decibels. The tone (speed of sound wave vibrations) is measured in cycles per second. The standard battery of hearing tests varies depending on whether the patient is an infant, child or adult.

Hearing impairment (deafness/hearing loss): A reduction in the ability to perceive sound that is classified as mild, moderate, severe or profound.

Pure tone average (PTA): Average air conduction threshold measured with an earphone.

Traditional hearing aid: A non-implanted, non-disposable on-ear or in-ear device that is FDA-approved and dispensed only by prescription.

Exclusions and Limitations

When hearing aid benefits exist in a health plan, limitations may include a dollar maximum and/or frequency of benefit availability (e.g. once every 36 months or once every 48 months).

Oregon

Oregon has a specific statute that mandates a benefit level of coverage set by the state and adjusted annually for one nondisposable hearing aid per hearing impaired ear for covered members who are 18 years of age or younger OR 19 to 25 years of age and enrolled in a secondary school or an accredited educational institution. More information regarding covered and non-covered services and other administrative criteria for dispensing hearing aids and the frequency of replacements can be found at the following link: https://www.oregonlegislature.gov/bills_laws/lawsstatutes/2013ors743A.html. (See section 743A.141 Hearing Aids). Accessed December, 2014. (5) (See Scope)

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Background

This policy was created in March 2014. Since that time, the policy has been reviewed on a regular basis and updated as needed. The most recent review was performed through December 2014.

Hearing loss is described as conductive, sensorineural, or mixed, and can be unilateral or bilateral. The American Speech - Language - Hearing Association (ASHA) has defined the degree of hearing loss based on pure-tone average (PTA). The PTA is the average air-conduction threshold for 1000 and 2000 Hz, and 3000 Hz measured with an earphone. Normal hearing is the detection of sound at or below 20 decibels (dB). (1)

The degree of hearing loss based on PTA detection thresholds is defined as:

Mild hearing loss (20 to 40 dB)

Moderate hearing loss (40 to 60 dB)

Severe hearing loss (60 to 80 dB)

Profound hearing loss (greater or equal to 80 dB)

Hearing Instrument/Aids

A hearing aid is an electronic device used to help members with a hearing impairment by providing sound amplification through the use of a microphone, amplifier and receiver. Members with moderate to severe sensorineural hearing loss are usually fit with acoustic hearing aids that are worn externally. An air-conduction (AC) hearing aid can benefit members with sensorineural, conductive, or mixed hearing loss. Contralateral routing of signal (CROS) is a system in which a microphone on the affected side transmits a signal to an air-conduction hearing aid on the normal or less affected side. (2) Hearing aids that are marketed for use by the general public should have approval from the U.S. Food and Drug Administration (FDA).

Hearing Aid Styles

There are two hearing aid styles. (3)

The body level instrument/aid (worn on the body) is not commonly prescribed and yet may be used for patients, including infants, whose ears are too small to hold a behind the ear aid.

The ear level instrument/aid (worn on and/or in the ear) is categorized by where on the ear the device is worn:

Behind the ear (BTE)

Completely in the canal (CIC)

In the canal (ITC)

In the ear (ITE)

The receiver that fits in the ear canal for all hearing aids requires a mold and is custom-fitted to the patient.

Hearing Aid Types

There are three types of hearing aids.(3)

Analog hearing aids convert sound waves that are amplified as an electrical signal in proportion to the sound signal. Though it has few adjustment options for the audiologist to fine-tine the instrument to meet the member’s amplification needs. Analog aids are a relatively inexpensive option. However, analog hearing aids are being replaced by digital technology.

Digital hearing aids convert sound waves into numerical codes before amplifying them, similar to binary computer code. This technology is more flexible with options for fine tuning the hearing aid to the member’s hearing needs by the audiologist and user.

Digital hybrid hearing aids have both analog technology for sound processing and digital technology for programming. Hybrid aids offer more options for the audiologist and user to adjust the “channels” to meet a variety of listening environments.

Accessories

Adapters for telephones are not covered.

Batteries and cords often are not covered.

Benefits for the following are often included in the hearing aid benefit limits or may not be covered:

Ear molds

Hearing aid dispensing fees

Hearing aid fittings

Over-the-Counter Hearing/Listening Assistive Devices

Over-the-counter hearing assistive devices/sound amplifiers available without a prescription are not covered. These include but are not limited to the following:

NewEar™

Pocketalker®

TV Ears®

Repair/Replacement

Benefits for hearing aid repair/replacement services are often included in the hearing aid benefit limits or may not be covered. (See Scope)

Regulatory Status

Air conduction hearing aids that are intended to compensate for hearing loss, are regulated by the U.S. Food and Drug Administration (FDA). The FDA does not consider sound amplifiers to be medical devices when labeled for recreational or other use by individuals with normal hearing. However, certain safety regulations related to sound output levels still apply to these products. (4)

Medicare National Coverage

Hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are excluded from coverage. (6)